Policies to reduce the exposure of children to environmental tobacco smoke: fact sheet No. 3.7, May 2007

This indicator illustrates the existence and stage of implementation and enforcement of national legal instruments to ensure smoke-free areas, smoke-free public transport, restricted advertising of tobacco products and bans on the sale of tobacco to minors. Legal instruments are effective tools to provide pro- tection against exposure to tobacco smoke. Most countries in the WHO European Region are implementing policies to restrict smoking in public areas and on public transport, the direct advertisement of tobacco products and the sale of tobacco products to minors, with the aim of reducing the exposure of children to tobacco smoke in pub- lic areas and discouraging active smoking. However, some countries still have no legal restrictions on smoking, even in health care or educational facilities. The exposure of children to tobacco smoke, both before and after birth, has been linked to multiple health impacts, including sudden infant death syn- drome (SIDS), respiratory problems, cancer and impaired mental and social development. RATIONALE Composite index of capacity to implement policies to reduce exposure to environmental tobacco smoke (ETS) and promote smoke-free areas for children Policies to reduce the exposure of children to environmental tobacco smoke FACT SHEET NO. 3.7 · MAY 2007 · CODE: RPG3_Air_A1 KEY MESSAGE This summary is based on data on the capacity to implement policies to reduce the exposure of children to ETS (also known as exposure to second-hand tobacco smoke or passive smoking) and promote smoke-free areas for children. Fig. 1. Proportion of countries in the WHO European Region implementing policies to reduce exposure of children to ETS Source: WHO Tobacco Control Database (1). 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Proportion of countries Health care facilities Education facilities Bars and restaurants Theatres and cinemas Public transport Advertisement of cigarettes Sale of tobacco to minors ban restriction no restriction no data Fact sheet 3.7 22.05.2007 2:04 Uhr Seite 1 PRESENTATION OF DATA Figure 1 indicates the percentage of the 52 countries in the Region which either do or do not have a relevant policy contributing to the summary indicator (i.e. bans or restrictions on smoking, advertisement of tobacco products and sale of tobacco to minors). Figure 2 represents the score of the indicator by country. A higher score reflects a more extensive scope and comprehensive policies. The composite index was calculated on the basis of data retrieved from the WHO tobacco control database as of September 2006 (1). HEALTH – ENVIRONMENT CONTEXT Exposure to ETS is defined as the involuntary breathing of air contaminated with tobacco smoke. It is well established that such expo- sure increases the risk of lung cancer. Epidemi- ological evidence and mechanistic studies show that ETS increases the risk of morbidity and mortality from cardiovascular disease in non-smokers (2). Smoking by mothers, exposure to ETS during pregnancy and exposure of children to ETS all cause an increased risk of SIDS, low birth weight, reduced lung function, asthma, lower respiratory tract infections and middle ear infection in children. Prenatal and postnatal exposure may also be associated with reduc- tions in mental and social development. Sever- al studies suggest that exposure to ETS may be causally associated with childhood cancer (3). A detailed review of exposure to ETS in Euro- pean countries can be found in ENHIS-2 fact sheet No. 3.4 of May 2007 on the exposure of children to ETS (4). According to the most recent estimates, ETS causes more than 79 000 deaths each year in the 25 countries of the EU (5). These estimates include deaths from heart disease, stroke, lung cancer and some respiratory diseases. Howev- er, they omit deaths in adults due to other con- ditions related to exposure to ETS (such as pneumonia) and do not reveal the burden of the serious acute and chronic morbidities caused by passive smoking. POLICY RELEVANCE AND CONTEXT The WHO Framework Convention on Tobac- co Control (FCTC), the first legal instrument designed to reduce tobacco-related deaths and disease around the world, came into force in February 2005 (6). The FCTC has been rati- fied by most of the reporting states, and those that have not yet ratified it are taking the final steps towards doing so. The FCTC requires countries to enforce restrictions on tobacco advertising, sponsorship and promotion; set parameters for new packaging and labelling of tobacco products that provide reliable infor- mation about the health effects, hazards and emission of tobacco smoke; establish clean indoor air controls; and strengthen legislation to eliminate all forms of illegal trade in ciga- rettes and other tobacco products. The European Strategy for Tobacco Control (7) reflects increased political commitment to, and public health expectations from, tobacco control in the European Region. It was adopt- ed by the WHO Regional Committee for Europe in September 2002 and provides an evidence-based framework and guidance for effective national action and international cooperation. The strategy specifies guidelines for action in the Region to be carried out through national policies, legislation and action plans. It also makes recommendations on monitoring, evaluating and reporting on tobacco use and tobacco control policies. Finally, it specifies mechanisms, tools and a timeframe for international cooperation. In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Chil- 0 2 4 6 8 10 12 14 Fig. 2. Degree of implementation of policies to reduce exposure of children to ETS in the WHO European Region 0 2 4 6 8 10 12 14 Score Malta Ireland Estonia Ukraine TFYR Macedonia* Spain Norway Netherlands Latvia Italy Israel Finland Czech Republic Belgium Turkmenistan Slovakia Romania Portugal Poland Lithuania Iceland Hungary France Bulgaria Bosnia and Herzegovina Belarus Turkey Sweden Slovenia Russian Federation Greece Croatia Azerbaijan Austria Serbia and Montenegro* Republic of Moldova Luxembourg Kazakhstan Germany Georgia Armenia Denmark United Kingdom Switzerland Albania Uzbekistan Tajikistan Kyrgyzstan Note. No data available for Andorra, Cyprus, Monaco and San Marino. *TFYR Macedonia = The former Yugoslav Republic of Macedonia *Serbia and Montenegro became two separate Member States of WHO in September 2006. In this fact sheet the data refer to before that date and relate to the then entity of Serbia and Montenegro (Serbia). Source: WHO tobacco control database (1) as of September, 2006. Fact sheet 3.7 22.05.2007 2:04 Uhr Seite 2 dren’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environment-related diseases in children (8). One of the goals (RPG III) aims at preventing and reducing respiratory diseases due to out- door and indoor air pollution, thereby con- tributing to a reduction in the frequency of asthmatic attacks, and ensuring that children can live in an environment with clean air. ETS is the dominant form of indoor air pollution where tobacco is smoked, even in areas that are properly ventilated. The European Union (EU) plays an active role in global tobacco control policies, and it rati- fied the FCTC in July 2006. The Community’s tobacco control activities include legislative measures such as Council Recommendation 2003/54/EC on the prevention of smoking and initiatives to improve tobacco control (9), Tobacco Products Directive 2001/37/EC “on the approximation of the laws, regulations and administrative provisions of the member states concerning the manufacture, presenta- tion and sale of tobacco products” (10), Tobacco Advertising Directive 2003/33/EC on “the approximation of the laws, regulations and administrative provisions of the member states relating to the advertising and sponsor- ship of tobacco products” (11), tobacco con- trol projects under the Public Health Pro- gramme and information campaigns (e.g. “Feel Free to Say No” 2002–2004; “HELP - For a life without tobacco” (12)). The compre- hensive antismoking strategy supports Europe- wide smoking prevention and cessation activi- ties, including health education measures, improved consumer information and assis- tance, and restrictions on the advertising and marketing of tobacco. The EU is also integrat- ing tobacco control into a range of other Com- munity policies in areas such as taxation and agriculture. In January 2007 the Commission presented the Green Paper Towards a Europe free from tobacco smoke: policy options at EU level and opened a new strategy aiming “to launch a broad consultation process and an open public debate, on the best way forward to tackle passive smoking in the EU” (13). It should be stressed that the indicator is an indirect measure of the exposure of children to ETS. It is not able to assess the extent to which regulations covering public spaces affect smoking behaviour in private spaces and thus reduce the risk of the exposure of children to ETS at home. ASSESSMENT The most common instruments used to reduce exposure to ETS are laws dealing with aspects of smoking. Legislation to prevent the expo- sure of non-smokers, and children in particu- lar, to ETS in public places are in place in most countries in the Region. In all countries poli- cies are based on the principle that non-smok- ers should be protected from ETS in all public indoor environments. Policies tend not to focus exclusively on children, although they are generally considered a priority group. Many countries place a focus on child-specific environments such as nurseries, kindergartens, schools and play areas. The indicator shows that most countries have introduced a wide range of comprehensive policies regulating tobacco, although many could go further. Three quarters of the coun- tries have banned smoking in education and health care facilities. Most national legislation prohibits smoking in theatres and cinemas. Smoking in restaurants and bars is regulated less strictly: 15% of countries have imposed a ban, around 60% have some restrictions in place, and a quarter have no restrictions. Stronger policies should be implemented to protect the health of staff and customers in bars and restaurants, where the customers often include children and adolescents. The advertising of cigarettes and the sale of tobac- co products to minors have been banned in more than 80% of the countries in the Region. EU member states have been implementing stronger smoking control measures since European Council Recommendation 2003/54/ EC (9) and most of them have enforced laws in response to EU Directives 2003/33/EC (10) and 2001/37/EC (11). DATA UNDERLYING THE INDICATOR Data source WHO tobacco control database (1). Description of data The tobacco control database (1) covers 41 indicators on tobacco use and control policies in 48 Member States in the Region. The data are drawn mainly from the regional survey of country-specific data (provided by the WHO national counterparts for the Action Plan for a Tobacco-free Europe) first undertaken in 2001, and other internationally recognized sources. The database covers five main areas: smoking prevalence, legislation, economics, cessation and general policy. It is constantly updated. An important advance on the 2001 exercise is that countries' information about their national legislation on tobacco control has been directly checked and cross-checked with information received from other sources. Country data on three additional sub-indica- tors were collected for the purpose of this fact sheet: smoke-free public areas, smoke-free public transport and direct advertising of tobacco products. The data were collected in a meta-data sheet and assessed according to the scoring system. Method of calculating the indicator For each component the following scoring is accepted: 0 – No restriction or prohibition 1 – Partial restriction, prohibition or volun- tary agreement 2 – Complete ban or prohibition. The index is computed as a sum of the score of seven components, SUM (Ci), where Ci is the score for component i. Maximum value of the indicator (a score of 14) means that all aspects are fully regulated, providing maximum legal protection for children against exposure to ETS in public spaces. The full list of components (Ci) is as follows: 1. Smoking prohibited in health care facilities 2. Smoking prohibited in education facilities 3. Smoking prohibited in bars and restaurants 4. Smoking prohibited in theatres and cinemas 5. Smoking prohibited in public transport vehicles (combined component of seven means of transport: buses, taxis, trains, domestic and international air transport, domestic and international water transport) 6. Advertisement of tobacco products in national mass media prohibited 7. Sale of tobacco to minors prohibited (com- bined component: sale of tobacco to per- sons aged under 16 years not allowed and/or imposition of penalties such as fines for such sales). Geographical coverage 52 countries in the WHO European Region. Period of coverage The analysis is based on the latest available information. The database was accessed on August 2006. Frequency of update The database is reviewed and updated on a regular basis in close collaboration with the national counterparts for the European Strate- gy for Tobacco Control. Data quality The tobacco control database does not cover regulations about smoke-free areas which are of particular relevance for children such as sports arenas, gymnasiums and other exercise facilities. Fact sheet 3.7 22.05.2007 2:04 Uhr Seite 3 References 1. Tobacco control database [online database]. Copenhagen, WHO Regional Office for Europe, 2006 (http://data.euro.who.int/tobacco/, accessed 2 March 2007). 2. Air quality guidelines for Europe, 2nd ed. Copenhagen, WHO Regional Office for Europe, 2000 (WHO Regional Publications, European Series, No. 91; http://www.euro.who.int/air/activities/20050223_3, accessed 2 March 2007). 3. Courage CM, Tamburlini G, von Ehrenstein OS. Environmental tobacco smoke. In: Tamburlini G, von Ehrenstein OS, Bertollini R, eds. Children’s health and environment: a review of evidence. Copenhagen, European Environment Agency and the WHO Regional Office for Europe, 2002 (Environmental issue Report No. 29) (http://www.euro.who.int/document/e75518.pdf, accessed 2 March 2007). 4. WHO European Centre for Environment and Health. Exposure of children to environmental tobacco smoke. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 3.4). 5. Smoke Free Partnership. Lifting the smokescreen – 10 reasons for a smoke free Europe. Brussels, European Respiratory Society, 2006 (http://www.ersnet.org/ers/show/default.aspx?id_attach=13509, accessed 4 March 2007). 6. WHO Framework Convention on Tobacco Control (WHO FCTC). Geneva, World Health Organization, 2003 (http://www.who.int/tobacco/framework/en/, accessed 2 March 2007). 7. European strategy on tobacco control. Copenhagen, WHO Regional Office for Europe, 2002 (http://www.euro.who.int/Document/E77976.pdf, accessed 2 March 2007). 8. Children’s Environment and Health Action Plan for Europe. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (EUR/04/5046267/7) (http://www.euro.who.int/document/e83338.pdf, accessed 2 March 2007). 9. Council of the European Union. Council recommendation of 2 December 2002 on the prevention of smoking and on initiatives to improve tobacco control, 2003/54/EC. Brussels, Publications Office, 2007 (http://eur-lex.europa.eu/smartapi/cgi/sga_doc?smartapi!celexapi!prod!CELEXnumdoc&lg=en&numdoc=32003H0054&model=guichett, accessed 2 March 2007). 10. Directive 2001/37/EC of the European Parliament and of the Council of 5 June 2001 on the approximation of the laws, regulations and administrative provisions of the Member States concerning the manufacture, presentation and sale of tobacco products. Official Journal of the European Union, L 194/26, 18.07.2001 (http://europa.eu.int/eur-lex/en/archive/2001/l_19420010718en.html, accessed 4 March 2007). 11. Directive 2003/33/EC of the European Parliament and of the Council of 26 May 2003 on the approximation of the laws, regulations and administrative provisions of the Member States relating to the advertising and sponsorship of tobacco products. Official Journal of the Euro- pean Union, L 152/16, 20.06.2003 (http://europa.eu.int/eur-lex/en/archive/2003/l_15220030620en.html, accessed 4 March 2007). 12. EU anti-smoking campaign “HELP – For a life without tobacco” [web site]. Brussels, European Commission, 2005 (http://www.help-eu.com, accessed 4 March 2007). 13. Green Paper. Towards a Europe free from tobacco smoke: policy options at EU level. Brussels, Commission of the European Communities, 2007 (Com2007 27 final) (http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/gp_smoke_en.pdf, accessed 2 March 2007). Further information Policies to reduce exposure to environmental tobacco smoke. Report on a WHO Working Group Meeting, Lisbon, Portugal, 29–30 May 2000 (EUR/00/5020495; http://www.euro.who.int/document/e70610.pdf, accessed 4 March 2007). WHO European strategy for smoking cessation policy. Copenhagen, WHO Regional Office for Europe, 2004 (European Tobacco Control Policy Series, No. 1; http://www.euro.who.int/document/e80056.pdf, accessed 4 March 2007). Legislating for smoke-free workplaces. Copenhagen, WHO Regional Office for Europe, 2006 (European Tobacco Control Policy Series, No. 3; http://www.euro.who.int/document/E88864.pdf, accessed 4 March 2007). ASPECT Consortium. Tobacco or health in the European Union – Past, present and future. Luxembourg, Office for Official Publications of the European Communities, 2004 (http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/Documents/tobacco_fr_en.pdf, accessed 4 March 2007). Health-EU. The public health portal of the European Union [web site]. Tobacco. Brussels, Commission of the European Communities, Directorate-General for Health and Consumer Protection, 2007 (http://ec.europa.eu/health-eu/my_lifestyle/tobacco/index_en.htm, accessed 2 March 2007). Directorate-General of Health and Consumer Protection [web site]. Public Health – Tobacco. Brussels, HCommission of the European Communities, 2007 (http://ec.europa.eu/health/ph_determinants/life_style/Tobacco/tobacco_en.htm, accessed 4 March 2007). Authors: Tibor Malnasi, National Institute of Environmental Health, Budapest, Hungary; Eva Kunseler, National Public Health Institute, Kuopio, Finland. © 2007 World Health Organization All rights reserved. The views expressed do not necessarily represent the decisions, opinions or stated policy of the European Commission or the World Health Organization. For further information, see the web site of the WHO European Centre for Environment and Health, Bonn www.euro.who.int/ecehbonn. World Health Organization · Regional Office for Europe Scherfigsvej 8 · DK-2100 Copenhagen Ø · Denmark · Tel.: +45 39 17 17 17 · Fax: +45 39 17 18 18 · postmaster@euro.who.int · www.euro.who.int Fact sheet 3.7 22.05.2007 2:04 Uhr Seite 4